Pathways to Universal Health Coverage: A Qualitative Comparative Analysis of Effective Development Cooperation Principles in Fragile and Conflict‑Affected States

Aweesha, Huzeifa; Pulkki-Brännström, Anni-Maria; Hurtig, Anna-Karin; San Sebastian, Miguel

Pathways to Universal Health Coverage: A Qualitative Comparative Analysis of Effective Development Cooperation Principles in Fragile and Conflict‑Affected States

Articles in Press

Document Type : Original Article

Authors

Huzeifa Aweesha

Anni-Maria Pulkki-Brännström

Anna-Karin Hurtig

Miguel San Sebastian

Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden

Abstract

Background
Universal health coverage (UHC) is a central target of the Sustainable Development Goals (SDGs), yet progress remains limited, particularly in fragile and conflict-affected states (FCAS). Despite commitments to leave no one behind, FCAS face complex circumstances that require better collaboration. Evidence on whether and how adherence to effective development cooperation (EDC) principles influences development outcomes remains scarce. This study examined which EDC principles have affected UHC attainment in FCAS.

Methods
Crisp-set qualitative comparative analysis (QCA) was applied to examine six EDC indicators as explanatory variables (conditions) which are EDC indicators: alignment with plans and budget priorities, partner coordination, national coordination mechanisms, use of national monitoring and evaluation (M&E) system, and provision of joint technical assistance (TA). The outcome was attainment of UHC service coverage index of at least 40. QCA assessed necessary conditions (for outcome to happen they must be present) and sufficient conditions (whenever they are present the outcome happens). We examined 17 FCAS; all were low and low. Seventeen low-income and lower-middle-income FCAS were included, using publicly available 2021 data on conditions and outcome.

Results
While none of the six conditions were found to be necessary for attaining UHC within our data, four appeared sufficient. The final solution indicated that either strong alignment with national plans or joint TA provided a pathway to UHC. The model had moderate coverage of 46%, explaining fewer than half of cases attaining the UHC threshold. Findings should be interpreted considering the small sample size, reliance on self-reported EDC ratings, and crosssectional data rather than assessment over time.

Conclusion
Better alignment among health partners is needed to minimise loss of already scarce and crucial resources in FCAS. Context-tailored TA may support attainment and sustainability of cooperation outcomes. Enhancement of frameworks and measures for tracking EDC and UHC with more frequent monitoring is needed.

Keywords

Effective Development Cooperation

Universal Health Coverage

Sustainable Development Goals

Fragile and Conflict-Affected States

Qualitative Comparative Analysis

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